practical exam 2 ===================================================== brainX Digital Learning System Study Session of KnowledgeBase: Practice Exam 2 Record # 1 Question/Fact: A 55-year-old

man with a past medical history significant for diabetes for 15 years presents to your office complaining of increasing shortness of breath over the past few months. Although he is pain-free today, he has had angina-like chest pain over the last several months. There is no radiation of the pain or nausea, vomiting, or diaphoresis. The patient's medications consist of metformin, glyburide, and lisinopril. He denies alcohol, tobacco, or illicit drug use. On physical examination, the patient appears as an age-appropriate obese male. Blood pressure is 130/170 mm Hg, and heart rate is 66/min. Jugulovenous distention is present. There is an S3 gallop with lateral displacement of the point of maximal impulse and some minimal rales at the lung bases. There is no peripheral edema. An EKG reveals a normal sinus rhythm at a rate of 64/min with no ST elevation and no T wave inversions. Anterior and inferior leads have QS waves. An echocardiogram reveals four chamber dilatation, global hypokinesis, and an ejection fraction of 35%. What is the next diagnostic step for this patient? (A) Coronary angiography (B) 24-hour Holter monitor (C) Transesophageal echocardiogram (D) Thallium stress test (E) Endomyocardial biopsy

Record # 2 Question/Fact: A 55-year-old man complains of epigastric burning. The burning is nonradiating but lasts for hours and is worsened by meals. An upper gastrointestinal series is performed, which reveals a benign-appearing, 1-cm ulcer in the antrum. There is no melena, hematochezia, fever, chills, dysphagia, odynophagia, or weight loss. He is treated with omeprazole and describes an immediate relief of pain. Which of the following should be performed? (A) Obtain an H. pylori antibody to determine if he should be treated with antibiotics (B) Arrange a repeat endoscopy in 4 to 6 weeks to verify healing of the ulcer (C) He should avoid aspirin and NSAIDs (D) No dietary restrictions are necessary (E) All of the above are appropriate recommendations Record # 3 Question/Fact: A 25-year-old man comes to your office complaining of pain in the right eye, which started three days ago. The pain was associated with blurred vision and hypersensitivity to light on Day 1. The problem increased gradually and was associated with redness of the eye and increased lacrimation. The patient denies a problem of this type in the past. He has been having some bilateral, deep, and dull pain in the gluteal region with mild lower backache and stiffness, which is worse in the morning and improves by the time he starts working in his office 1 to 2 hours later. The patient uses analgesics for the backache. He has been married for the last year, is a computer programmer, and goes to the gym three days a week. On physical examination, the patient is healthy-looking but anxious. He has a hazy cornea in the right eye with precipitates on the corneal endothelium and yellowish spots on the iris with indistinct margins. Funduscopy, after dilation, shows a grossly normal retina and choroid. His left eye is normal. The rests of the physical examination shows some limitation in the range of movement of the lumber spine in all directions and vague tenderness deep in the gluteal region. The ESR is 60 mm/h, and the urinalysis and chemistries are normal. An x-ray shows slightly blurred cortical margins of the subchondral bones in the sacroiliac joints bilaterally. Which of the following would be most appropriate next action? (A) Culture from the urethra (B) Serological test for syphilis (C) HLA-B27 typing (D) Methylprednisolone (E) Steroid eye drops

Record # 4 Question/Fact: A 38-year-old man presents to the emergency department with shortness of breath and chest tightness. He has a past medical history of nephrotic syndrome and is currently taking prednisone. He just completed a 5-day course of azithromycin for an upper respiratory infection but still has a cough. On physical examination, his temperature is 100.8 F, pulse is 118/min, blood pressure is 115/70 mm Hg, and he appears to be in respiratory distress. The lung examination reveals rightsided splinting. The heart examination is normal. Laboratory examination reveals: white blood cell count 16,000/mm3 with 88% neutrophils. An arterial blood gas on room air shows a pH of 7.44, a pCO2 of 32 mm Hg, a pO2 of 79 mm Hg, and a 95% oxygen saturation. The chest x-ray reveals atelectasis and a right lower lobe infiltrate. Which of the following is the most likely cause of this patient's problem? (A) Amyloidosis (B) Focal segmental glomerular sclerosis (C) Membranous nephropathy (D) Diabetic nephropathy (E) Minimal change disease Record # 5 Question/Fact: A 40-year-old man presents to your office after a syncopal episode at work today. He has high blood pressure but has not been adherent with his medical appointments. He also has a history of diet-controlled diabetes. Review of systems is remarkable for dyspnea on exertion with intermittent lightheadedness. The episodes last for 2 to 5 minutes. His medications include an anxiolytic medication prescribed by a friend. His blood pressure is 160/94 mm Hg, and his pulse is 78/min. Cardiac examination is remarkable for a sustained point of maximal impulse and a IV/VI systolic ejection murmur loudest at the lower left sternal border. The murmur increases with Valsalva. An EKG in your office shows left ventricular hypertrophy. What would be the most appropriate management of his hypertension? (A) Beta-blocker (B) ACE inhibitor (C) Diuretic (D) Calcium-channel blocker (E) Angiotensin-receptor blocker Record # 6 Question/Fact: A 78-year-old white woman is brought to the emergency department unconscious and intubated by paramedics. The patient was found lying unresponsive on the bathroom floor with a heart rate of 30/min. She was apneic and hypotensive with a systolic blood pressure of 60 mm Hg. They gave atropine 1 mg intravenously in the field. The family arrives and tells you that she has a history of congestive heart failure, coronary heart disease, and hypertension and takes furosemide, metoprolol, digoxin, and enalapril. On admission to the emergency department, she has a temperature of 100 F, a heart rate of 35/min, and a blood pressure of 60/40 mm Hg. You give another dose of atropine 1 mg intravenously without any change in the heart rate or blood pressure. Her potassium is 3.6 mEq/L, with a bicarbonate of 22 mEq/L, BUN of 50 mg/dL, and a creatinine of 2.3 mg/dL. An EKG shows third-degree AV block at a ventricular rate of 35/min. Her toxicology screen is negative. What would you do next? (A) Gastric lavage using activated charcoal (B) Digibind (C) Lidocaine (D) Potassium (E) Transcutaneous pacing Record # 7 Question/Fact: A 64-year-old man presents to your office for his yearly physical. This is his first visit to your office, and he admits that he has not been to a physician in over a decade. He takes no medications and denies tobacco or alcohol use. He is a recently retired accountant and started "health walks" three times a week, for 45 minutes at a time. He has been keeping salt out of his diet, going to yoga classes, and trying to lose weight for the last six months. At a local mall, his blood pressure was read as 160/80 mm Hg at a free screening booth. On physical examination, his weight is 80 kg (176 lbs), and he stands 58" tall. Blood pressure taken in the office is 154/88 mm Hg, heart rate is 74/min, and

temperature is normal. The physical exam shows AV nicking on funduscopic evaluation. The EKG has normal sinus rhythm at 74/min with no ST changes. The following lab results are available: Sodium 143 mEq/L, potassium 5.0 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 1.1 mg/dL, glucose 96 mg/dL; cholesterol (total) 210 mg/dL, HDL 50 mg/dL, triglycerides 180 mg/dL, LDL 124 mg/dL, VLDL 36 mg/dL. Urinalysis is normal. What is the next appropriate step regarding the management of this patient? (A) ACE inhibitor (B) Atenolol and simvastatin (C) Advise further lifestyle modification and recheck blood pressure in 4 to 6 weeks (D) Hydrochlorothiazide (E) Repeat the blood pressure Record # 8 Question/Fact: A 42-year-old woman presents to the hospital with the sudden onset of shortness of breath associated with chest pain. The pain does not radiate and increases on inspiration. On physical examination, blood pressure is 110/80 mm Hg, pulse is 116/min, and respirations are 22/min. She is 125 pounds. An EKG reveals sinus tachycardia at 120 beats per minute, and the chest x-ray is normal. Baseline prothrombin time (PT) is 12 seconds, and the partial thromboplastin time (PTT) is 28 seconds. The patient is bolused with 5,000 units of heparin and then started on a drip of 1,000 units per hour. The V/Q scan gives a high probability for a pulmonary embolus. Six hours later, the repeat PT is 12.5 seconds, and the PTT is 30 seconds. She is rebolused with 5,000 units of heparin, and the drip is raised to 1,100 units per hour. Six hours later, the PT is 12.4 seconds, and the PTT is 31 seconds. What is the most likely reason for this scenario? (A) Lupus anticoagulant (B) Anticardiolipin antibodies (C) Factor V mutation (D) Antithrombin III deficiency (E) Protein S deficiency Record # 9 Question/Fact: A 47-year-old man with a history of diabetes mellitus and a 40-pack-per-year smoking history presents to the emergency department at 6 A.M. with the acute onset of nausea, vomiting, and diaphoresis that woke him up from sleep. An EKG is done and shows ST elevation in leads II, III, and aVF. His vital signs are: temperature 98.5 F; pulse 72/min; respirations 22/min, and blood pressure 70/50 mm Hg. A Swan-Ganz (pulmonary artery) catheter is placed emergently. Which of the following readings would you expect to see? Record # 10 Question/Fact: A 36-year-old woman comes to the cardiology clinic with complaints of shortness of breath on minimal exertion, which has been getting progressively worse over the past seven months. Six months ago, she delivered twins. For the last month of pregnancy, she felt short of breath after walking one block and noticed mild ankle edema, which she attributed to the natural course of pregnancy. After delivery, these symptoms became progressively worse. Now she also describes nocturnal dyspnea and states that lately she uses at least three pillows to sleep and cannot lie down flat at all. This was her fourth pregnancy, and her past medical history is unremarkable. She is trying to be compliant with fluid restriction. Her medications at this time are carvedilol, lisinopril, and furosemide. The patient presents as an obese female, who is mildly short of breath at rest. Physical examination findings are positive for distended jugular veins, the presence of an S3 gallop, and a III/VI systolic ejection murmur radiating to the axilla. There are mild crackles at both lung bases, as well as a 1+ lower extremity edema. Echocardiogram was done three months ago, and showed an ejection fraction of 27% and a moderately dilated left ventricle and left atrium. What would be most effective way to improve this patient's prognosis? (A) Increase dose of diuretics (B) Add hydralazine

(C) Cardiac catheterization (D) Myocardial biopsy (E) Cardiac transplantation Record # 11 Question/Fact: What is the appropriate mode of colorectal cancer screening for the following case? A 51-year-old -man with no family history of colon cancer and who is asymptomatic. (A) Colonoscopy now and every 10 years (B) Flexible sigmoidoscopy now and every 5 years (C) Colonoscopy at age 50 and every 10 years (D) Colonoscopy now and every 10 years (E) Stool occult cards every year; colonoscopy if positive (F) Colonoscopy at age 40 and every 5 years (G) Colonoscopy in 3 years (H) Colonoscopy in 1 year (I) Colonoscopy every 1 to 2 years Record # 12 Question/Fact: A 69-year-old woman with a history of severe coronary artery disease and a permanent pacemaker for tachybrady syndrome is admitted for dyspnea secondary to congestive heart failure. Her medications include digoxin, amiodarone, metoprolol, and furosemide. While in the telemetry unit, she develops torsades de pointes. She is initially treated with magnesium, atropine, and potassium. Her resting heart rate now is in the 40s. However, she continues having intermittent runs of torsade. The QT interval is 610 milliseconds. What is the next step in treating this dysrhythmia? (A) Increase the atrial rate of the pacemaker (B) Isoproterenol (C) Procainamide (D) Change oral amiodarone to intravenous (E) Defibrillation at 200 Joules (J) Record # 13 Question/Fact: A 62-year-old man presents to the emergency department with complaints of fever, chills, nausea, and pain on urination. On admission the patient appears dehydrated. He has not been eating or drinking for the past few days because he fears urination. He has been having progressively worsening dysuria and rectal pain on defecation for the past week. He denies urinary hesitance or incontinence. He has a low-grade fever that started two days before admission. On examination, the patient is noted to have suprapubic tenderness. Rectal examination reveals severe tenderness with a diffusely enlarged and boggy prostate. The stool is brown and negative for occult blood. He has a temperature of 101.9 F. The urinalysis shows 2+ blood, 1+ protein, 3+ white cells, and is positive for nitrites. His white blood cell count is 18,000/mm3. What is most appropriate for this patient? (A) Ampicillin and gentamicin (B) Cystoscopy (C) Gentle prostate massage (D) Increase fluid intake and administer one week of oral trimethoprim/sulfamethoxazole (E) Prostrate-specific antigen (PSA) level

Record # 14 Question/Fact: A 57-year-old woman presents to the clinic for a follow-up visit. She complains of swelling in her extremities and generalized headaches, which she has noted for the past few weeks. She also reports an elevated blood pressure during her last visit to her pharmacy, which has an automated blood-pressure machine. Her past medical history is significant for Addison's disease, atrophic gastritis, and hypercholesterolemia. Her current medications include prednisone 5 mg, simvastatin,

and ranitidine. She was recently started on fludrocortisone acetate 0.3mg daily. The patient states that she has been compliant with her medications. Her blood pressure is 182/91mm Hg, temperature is 96.9 F, and pulse is 70/min. Laboratory studies show: white blood cell count 6,200/mm3, sodium l56 mEq/L, potassium 2.6 mEq/L, chloride 102 mEq/L, bicarbonate 28 mg/dL, BUN 16 mg/dL, creatinine 0.9 mg/dL, and glucose 80 mg/dL. Which of the following is the next best step in the management of this patient? (A) Advise the patient to limit free water intake to one liter per day and to weigh herself daily (B) Add stress-dose hydrocortisone to the current regiment of prednisone (C) Decrease the dose of fludrocortisone (D) Start spironolactone therapy (E) Order a panel of thyroid function testing

Record # 15 Question/Fact: A 24-year-old woman is being evaluated in the emergency room for occasional, self-resolving headaches. In the triage area, the patient has a continuous, generalized tonic-clonic seizure. According to her family, the patient has no prior history of a seizure disorder. The patient continues to be in tonic-clonic state. Her pulse is 118/min, with a blood pressure of 138/64 mm Hg and a normal temperature. The patient appears cyanotic, and she is intubated. She weighs 60 kg. The patient is given three milligrams of lorazepam intravenously but continues to have seizures. The medical resident physician orders the nurse to give another 3 mg of lorazepam, which has no effect. The patient continues to have seizures. What is next step in management? (A) Lumbar puncture (B) Antibiotics (C) Additional doses of lorazepam until the seizures stop (D) Intravenous fosphenytoin (E) Intravenous phenobarbital

Record # 16 Question/Fact: A 19-year-old Caribbean woman is admitted to the gynecology service because of an ectopic pregnancy. She has a history of bacterial endocarditis. She is allergic to penicillin. In addition to her left lower quadrant pain and fever, her physical exam is significant for a grade III/VI diastolic murmur. Blood pressure is 120/80 mm Hg. The EKG is normal, and the echocardiogram shows mitral stenosis with no visible vegetations. What is your recommendation for antibiotic prophylaxis prior to surgically removing the ectopic pregnancy? (A) Vancomycin and gentamicin (B) Amoxicillin (C) Clindamycin (D) Ampicillin and gentamicin (E) No antibiotics indicated

Record # 17 Question/Fact: A 31-year-old man was sent to your clinic by his dentist to be evaluated for gingival bleeding prior to tooth extraction. For the past two months the patient has been experiencing bleeding from his gums while brushing. He admits to several episodes of nosebleeds throughout his lifetime, which were somewhat severe and once required a visit to the emergency department. He denies melena, hematochezia, joint pain, or swelling. His father died at an early age of an unknown cause, and patient recalls that he also had nosebleeds. His vitals in your office are stable. His physical examination is unremarkable. No petechiae or purpura are seen on the skin. The oral mucosa is normal. The spleen is not palpable, and there are no joint deformities. Laboratory studies show the following: WBC 6,200/mm3; hematocrit 38%; platelets 360,000/mm3; PT 11.6 seconds; PTT 48.0 seconds; INR 1.3. Peripheral smear is normal, and bleeding time is mildly prolonged. The ristocetin cofactor activity is abnormal.

What would you do to make the dental extraction safe? (A) Desmopressin (B) No therapy (C) Aminocaproic acid (D) Factor VIII concentrate infusion (E) Cryoprecipitate

Record # 18 Question/Fact: A 39-year-old woman presents to your office complaining of worsening fatigue and malaise over the past 4 weeks. She says that she came to your office today because she has noticed that her eyes have become yellow and yesterday her skin became very itchy. She denies any history of alcohol use. She takes no medications but was treated for a urinary tract infection 6 weeks ago with a 7-day course of nitrofurantoin. Her only other complaints are of some mild occasional arthralgias in the small joints of her hands. Vitals are remarkable for a low-grade fever, but blood pressure and pulse are normal. Physical examination is remarkable for icteric sclera. The liver is palpated 3 cm below the costal margin and is slightly tender. There is no splenomegaly. Laboratory tests reveal: WBC 12,100/mm3, hematocrit 39%, platelets 245,000/mm3, albumin 3.8 g/dL, PT 12.0 seconds, PTT 22.5 seconds, AST 762 U/L, ALT 846 U/L, alkaline phosphatase 194 U/L, and total bilirubin 5.9 mg/dL. ANA test is positive with a titer of 1:640. Serum gamma globulin is 5.9 g/dL, and testing for anti-hepatitis C virus (HCV) antibody is negative.. Testing for hepatitis-B surface antigen is also negative. She refuses liver biopsy. What is the best next step in the treatment of this patient? (A) Prednisone and azathioprine (B) Cyclosporine (C) Methotrexate (D) Liver transplant evaluation (E) Interferon-alpha and ribavirin

Record # 19 Question/Fact: A 32-year-old woman came to the hospital with complaints of recurrent syncope for the last five years. She had her last syncopal episode two hours ago, which lasted for several seconds and was associated with chest discomfort, palpitations, and diaphoresis. She has history of Graves' disease for three years and for which she was originally treated with propylthiouracil and maintained on propranolol. The patient claims that her father had a heart attack at the age of 78 and her mother died suddenly at the age of 42. Telemetry during the current hospitalization shows multiple episodes of nonsustained, polymorphic ventricular tachycardia (VT) with an undulating amplitude and a prolonged QT interval during which she experienced lightheadedness followed by syncope. What is the best management for this patient? (A) Amiodarone (B) Implantable cardioverter/defibrillator (C) Stop propranolol (D) Cervicothoracic sympathectomy (E) Quinidine Record # 20 Question/Fact: A 52-year-old man presents to your office with shortness of breath, which has been progressively worsening, especially on exertion, over the past 6 months. He also awakens at night with shortness of breath and occasionally sleeps sitting up in a chair because of it. He denies chest pain, palpitations, diaphoresis, syncope, fever, cough, or night sweats. His past medical history is significant for hypertension, hypercholesterolemia, and childhood asthma. He has smoked one pack of cigarettes per day for the past 30 years and drinks 5 to 6, 8-ounce cans of beer each evening after work for the past 20 years. Current medications include atorvastatin 10 mg, hydrochlorothiazide 25 mg, and Tylenol occasionally for headaches. He denies any significant history of heart disease, diabetes, cancer, or renal disease. The patient's blood pressure is 169/92 mm Hg, respiratory rate is 18/min, heart rate is 90/min, and there is no presence of fever. Physical examination reveals a moderately obese male, who is well developed and well nourished. Significant findings include xanthelasma, jugulovenous distention, bibasilar crackles on lung auscultation, and a grade III/VI systolic murmur at the apex. Chest x-ray reveals cardiomegaly and pulmonary vascular congestion. An in-office echocardiogram reveals an enlarged and diffusely hypokinetic left ventricle with an ejection fraction of 30 to 35% and moderate mitral regurgitation.

Which of the following statements is most accurate? (A) The cause of this patient's condition has been linked to a hereditary syndrome. (B) Cardiac auscultation is most likely to reveal a fourth heart sound. (C) Stopping alcohol is the most important measure in the management of this patient. (D) The role of chronic anticoagulation should be considered in this patient. (E) Cardiac catheterization is indicated as the next step in the management of this patient. Record # 21 Question/Fact: A 26-year-old woman with bipolar disorder comes to your office feeling "fatigued and down" for the past month. She claims that she has been compliant with her lithium therapy for the past six months. She denies using alcohol, tobacco, or illicit drugs. She claims that she has been having trouble having bowel movements for a few weeks and that she has been using an over-the-counter fiber supplement. On examination, she has a temperature of 96.5 F, a heart rate of 60/min, and a blood pressure of 110/70 mm Hg. Her skin is dry, and there is minimal neck swelling. There are delayed deep-tendon reflexes in the knees bilaterally. Her white blood cell count is 6,500/mm3 with a hematocrit of 33%.

What is the best treatment for this patient? (A) Stop the lithium and restart at a lower dose when the thyroid normalizes (B) Switch lithium to valproic acid (C) Add fluoxetine and a laxative and monitor the TSH level closely (D) Add levothyroxine 50 g/day and monitor symptoms and TSH level (E) Start methimazole 30 mg/day until the symptoms abate Record # 22 Question/Fact: A 27-year-old woman presents to the emergency department complaining of shortness of breath for the last few hours that is not related to exertion or body position. The patient states that she is 22 weeks pregnant and this is her first pregnancy. She has never had an episode like this before. She denies fever, cough, or chest pain. The patient appears tachypneic and in moderate distress. Her temperature is 100.9 F, heart rate is 120 mm Hg, and the blood pressure is 110/60 mm Hg, with a respiratory rate of 30/min. The lungs are clear to auscultation, and the heart examination is unremarkable. She has moderate edema of the lower extremities with the left slightly worse than the right. An arterial blood gas on room air shows: pH 7.51, pCO2 26 mm Hg, pO2 62 mm Hg, and 92% saturation. The EKG shows sinus tachycardia at a rate of 126/min with no ST-T abnormalities. The chest x-ray shows clear lungs fields bilaterally. What is the most appropriate test to confirm the diagnosis? (A) V/Q scan (B) Spiral CT (C) Impedance plethysmography (D) D-Dimers (E) 125I fibrinogen scan

Record # 23 Question/Fact: A 57-year-old man presents to your office with complaints of multiple episodes of severe, unilateral, periorbital headaches over the last two weeks, as well as right now. The patient states that these headaches last approximately one hour and usually occur at night. They wake him from sleep. Sometimes they are accompanied by nasal stuffiness and lacrimation. He denies nausea or vomiting. He noticed that occasional alcohol intake or emotional stress at work precipitates his headache. He tried a large dose of acetaminophen with no significant relief. The patient also complains of periodic episodes of squeezing chest pain after walking 4 to 5 blocks. There is no recent change in the character of the chest pain. His pulse is 72/min, and his blood pressure is 130/80 mm Hg. Physical examination reveals Horner's syndrome on the left side. Which of the following is the most appropriate management for his headache? (A) Ibuprofen (B) Prednisone (C) Ergotamine

(D) Propranolol (E) Sumatriptan

Record # 24 Question/Fact: A 55-year-old man comes in to your office complaining of diarrhea. He states that he has had a history of Crohn's disease for many years, and it has been particularly aggressive over the past two years. Five months ago, he underwent a small bowel resection (250 cm of bowel) for a severe relapse of Crohn's that was not responsive to medical therapy. Shortly after this past surgery, he states that he has been experiencing diarrhea. He has about five bowel movements per day and he describes them as bulky, light-colored, and foul-smelling. He describes a weight loss of 30 lb over the past five months with no change in appetite. He appears to be slightly wasted and has several superficial hematomas on the skin. Otherwise, the physical examination is unremarkable. Laboratory studies show: WBC 8,200/mm3, hemoglobulin 11.3 g/dL, hematocrit 33.7%, platelets 238,000/mm3, and a mean corpuscular volume 104 m3. Chest x-ray shows clear lung fields. However, diffuse osteopenia is noted. Which of the following is the best way to treat this patient? (A) Oral vitamin B12 (B) Oral vitamin B12 and oral vitamins A, D, E, and K (C) Intramuscular (IM) vitamin B12 and oral vitamins A, D, E, and K (D) IM vitamin B12 and vitamins A, D, E, and K (E) IM vitamin B12, oral vitamins A, D, E, and K, and medium-chain triglycerides

Record # 25 Question/Fact: Patients undergoing chemotherapy with doxorubicin (adriamycin) can develop damage to the myocardium as the cumulative dose of the drug rises. There is an irreversible effect upon left-ventricular contractility and ejection fraction. Oncologists often have a critical decision to make between limiting the dose of the chemotherapeutic agent versus causing symptomatic congestive failure over time. What is the most accurate method of assessing the effect of the drug upon the patient? (A) Transthoracic echocardiogram (B) Transesophageal echocardiogram (C) Left heart catheterization (D) Right heart catheterization (Swan-Ganz)

Record # 26 Question/Fact: A 39-year-old Japanese man comes to your office after he has developed a festinating gait and poverty of voluntary movement. On physical examination, he has cogwheel rigidity of the limbs and a pill-rolling type of tremor at rest. His symptoms are moderate and do not interfere with his ability to dress himself or to care for himself in general. He started noticing these symptoms seven years ago, and they have been getting progressively worse. Over the past year, his face has become mask-like. An MRI and CT scan of the head show nothing abnormal. Which of the following would be appropriate for this patient? (A) Levodopa (B) Pramipexole or ropinirole (C) Sinemet (carbidopa and levodopa) (D) Benztropine (Cogentin) (E) Amantadine

Record # 27 Question/Fact: A 44-year-old-man presents for evaluation of increased abdominal girth. There has been no fever, chills, weight loss, or abdominal pain. He has also noted increased lower-extremity edema. Physical examination reveals that he is mildly icteric. The abdomen is nontender, but tense ascites are noted. There is lower extremity edema, spider angioma, and palmar erythema. Laboratory analysis reveals: WBC 2,500/mm3, hematocrit 33%, platelets 77,000/mm3, sodium 123

mEq/L, albumin 2.2 g/dL, bilirubin 3.3 mg/dL, AST 121 U/L, and ALT 88 U/L. Which of the following statements regarding this patient is false? (A) The patient has end-stage liver disease, Child's class C cirrhosis (B) If the ascites albumin is greater than 1.1, a malignancy may exist (C) The low platelet count is typically due to portal hypertension (D) Viral hepatitis A, B, or C could have caused this problem (E) The low sodium portends a poor prognosis Record # 28 Question/Fact: An 88-year-old man with a past history of hypertension and a previous myocardial infarction is admitted for syncope. His family says he was in a store and collapsed to the floor while looking at some books. He then proceeded to have a few jerking movements of both arms and legs, which disappeared spontaneously after a few seconds. A minute or so later, the patient awoke and could not recollect the event. He denies any chest pain, dizziness, or palpitations preceding the collapse. Current medications include aspirin, metoprolol, and hydrochlorothiazide. On examination, the blood pressure is 142/98 mm Hg, pulse is 65/min, and temperature is normal. His chest and abdomen are also normal. He has a 2/6 holosystolic murmur at the apex. An EKG shows a normal sinus rhythm at 62/min, with Q waves in leads V3-V6. There are no ST- or T-wave abnormalities. An echocardiogram shows segmental left ventricular systolic dysfunction and moderate mitral regurgitation. What is the most likely diagnosis for this patient's syncope? (A) Neurocardiogenic (vasovagal) (B) Paroxysmal ventricular tachycardia (C) Orthostatic hypotension (D) Tonic clonic seizure (E) Hypovolemia

Record # 29 Question/Fact: A 56-year-old woman comes to the clinic with pain in the wrists, knees, and fingers for several weeks. She has been taking ibuprofen for these symptoms. She has also begun noticing that she is unable to withstand staying out in the sun because the light bothers her eyes and she develops a rash on her cheeks. She has recently been found to have a reactive PPD skin test, and she was started on isoniazid several months ago. She has hypertension, diabetes, and gout. Her medications are metoprolol, metformin, and allopurinol. There has been no recent change in these medications. The physical examination shows a blood pressure of 129/84 mm Hg, a temperature of 37.0 F, and the rash on her face. Which of the following is most appropriate action? (A) Change her pain medications (B) Change her antigout medication (C) Change her antituberculosis medications (D) Corticosteroids Record # 30 Question/Fact: You are asked to see a 68-year-old white male in the intensive care unit who was admitted the previous night from a nursing home. He has increasing dyspnea, a fever, and leukocytosis. He was found to have a right lower lobe infiltrate on chest x-ray. He developed respiratory distress shortly after arrival to the emergency department and required mechanical ventilatory support. A left subclavian central venous line was placed. Two sets of blood cultures grew gram-negative rods. The patient was started on piperacillin/tazobactam 3.375 g intravenously every 6 hours. The ICU resident shows you multiple 2- to 3-cm ecchymosed areas on the upper and lower extremities. The patient is on the ventilator and is unresponsive to questions. The vital signs when you see him are: temperature 100 F, heart rate 110/min, respiratory rate 16/min, and blood pressure 100/60 mm Hg. When the patient was admitted, his hemoglobin was 10 g/dL, and the hematocrit was 30%. Today's labs were drawn and are as follows: WBC 15,000/mm3; hematocrit 27%; platelets 80,000/mm3 Differential: 90% neutrophils, 5% lymphocytes, and 5% monocytes PT 25 seconds (control 11 to 14 seconds), PTT 50 seconds (control, 25 to 35 seconds) Fibrinogen level is <100 mg/dL (normal 150-350 mg/dL). How should this patient be treated?

(A) Platelet transfusion and aminocaproic acid (B) Fresh frozen plasma (FFP) and cryoprecipitate (C) FFP and heparin (D) Platelets, cryoprecipitate, and FFP Record # 31 Question/Fact: A 61-year-old woman presents to her primary care clinic with difficulty breathing and swallowing, as well as throat and neck pain and voice changes over the past two months. She is very sensitive to cold and constantly feels tired. She also has fatty, foul-smelling stools. She denies abdominal pain, vomiting, or weight changes. She has itching, which has increased over the past month, and constantly experiences dryness of the mouth, which is unrelieved by drinking fluids. During the last visit to her gynecologist, she was found to have an immobile, painful, thickened cervix and was diagnosed with sclerosing cervicitis. The diagnosis was supported by cervical biopsy. On physical examination, her temperature is normal, and the pulse is 62/min. Her face looks slightly puffy, and her skin is dry and pale. There are xanthomatous lesions around the eyelids and on the face. The mucous membranes are dry. The thyroid gland is palpable, enlarged, asymmetrical, hard, and immobile. There is no tenderness on palpation of the thyroid. There is a mild lower extremity edema. Laboratory studies show: sodium 132 mEq/L, potassium 3.4 mEq/L, BUN 24 mg/dL, creatinine 0.9 mg/dL, cholesterol 290 mg/dL, triglycerides 168 mg/dL, TSH 34 mU/L (normal 0.4-5.0 mU/L), and free T4 0.6 ng/dL (normal 0.9-2.4 ng/dL). The thyroid radioiodine uptake is low, and the scan reveals uneven uptake. Antimitochondrial antibodies are present, and thyroid autoantibodies are negative. Thyroid-gland ultrasound reveals diffuse changes, with no nodular structures. An ultrasound-guided, thyroid-gland biopsy reveals an increased amount of fibrotic tissue. What would be the most effective treatment in this thyroid gland disorder? (A) Surgical decompression (B) Corticosteroids (C) Tamoxifen (D) Levothyroxine (E) Radiation therapy Record # 32 Question/Fact: A 65-year-old man comes to the clinic for a regular follow-up visit. He states that he feels well. He had a myocardial infarction 18 months ago. He currently takes aspirin, metoprolol, and atorvastatin 20 mg daily. The patient is a former cigarette smoker. He is normotensive, weighs 102 kg, and his height is 180 cm. He exercises four times a week and maintains a low-fat diet. He was able to lose only three pounds over the past five months. Prior to the infarction his lab tests showed: total cholesterol 240 mg/dL, LDL 153 mg/dL, HDL 25 mg/dL, and triglycerides 290 mg/dL. He was not on any diet or medications at that time. Currently, his labs after the start of medications are: total cholesterol 210 mg/dL, LDL 127 mg/dL, HDL 35 mg/dL, and triglycerides 250 mg/dL. Which of the following is the most appropriate next step? (A) Change atorvastatin to gemfibrozil (B) Continue atorvastatin 20 mg daily (C) Increase the dose of atorvastatin to 40 mg daily and check cholesterol profile in 4 to 8 weeks (D) Change atorvastatin to fluvastatin (E) Continue atorvastatin at the present dose and add cholestyramine Record # 33 Question/Fact: A 38-year-old woman is admitted to the hospital with complaints of nausea, vomiting, and generalized muscle weakness for the past 3 to 4 days. She was found to be HIV-positive two years ago. Her medications include zidovudine, lamivudine, nelfinavir, azithromycin, and Bactrim (trimethoprim/sulfamethoxazole). Physical examination reveals a thin female with a normal temperature and pulse, and a blood pressure of 100/50 mm Hg. There are multiple needle tracks on both upper extremities. The submandibular lymph nodes are 2 cm in size, nonpainful, and mobile. Cardiac sounds are normal, and lung auscultation reveals bibasilar crackles. The abdomen is unremarkable. There is no leg edema. Laboratory tests show: White cell count 3,400/mm3; hematocrit 36.4%; sodium 142 mEq/L; potassium 6.2 meq/L; chloride 122 mEq/L; bicarbonate 15 mEq/L; BUN 24 mg/dL; creatinine 1.2 g/dL; and glucose 98 mg/dL. Twenty-four-hour urine potassium excretion is 16 mmol/L (low). The serum aldosterone level in the supine position is 11 ng/dL (normal 2-5 ng/dL).

What test would you order next? (A) Serum cortisol (B) Kidney biopsy (C) Fludrocortisone stimulation test (D) Serum renin (E) Serum and urinary osmolality Record # 34 Question/Fact: A 63-year-old man with diabetes comes to the office with an ulcer on his foot for the past week. He has no fever. On physical examination, you find a 3 3-cm ulcer on the base of his foot. There is significant swelling and redness of the surrounding soft tissue. The area is warm to the touch. What is the best initial test? (A) X-ray (B) CT scan (C) MRI (D) Biopsy (E) Bone scan Record # 35 Question/Fact: A 35-year-old Asian man comes to the emergency department after a syncopal episode that occurred one hour ago while exercising. The patient spontaneously recovered five minutes later. He remembers having palpitations, shortness of breath, and dizziness prior to fainting. He recalls having occasional palpitations and dizziness for years. The patient has no significant medical history. On examination, his heart rate is 140/min, and his respiratory rate is 22/min. He is afebrile. The cardiac examination reveals a normal S1 and S2 with no audible murmurs or gallops. His respiratory and abdominal examinations are benign. There is no evidence of peripheral edema. Three sets of troponins, six hours apart, are within normal limits, and the chest x-ray reveals no cardiopulmonary disease. A cardiac electrophysiologic study was performed and produced sustained ventricular tachycardia. The EKG shows marked ST elevation in right precordial leads with an incomplete right bundle branch block. What is the best treatment for this patient? (A) Flecainide (B) Beta-blocker, nitroglycerin, aspirin, and oxygen (C) Verapamil (D) Amiodarone (E) Pacemaker placement (F) Implant cardioverter/defibrillator device Record # 36 Question/Fact: A 47-year-old man presents to your office complaining of progressively worsening episodes of shortness of breath. He has a history of asthma that has been well controlled with inhaled steroids, which he takes daily, and an albuterol inhaler, which he only needs to take approximately once to twice per month. He was hospitalized 6 weeks ago for new-onset stable angina and was discharged with sublingual nitroglycerine and low-dose aspirin, which he takes daily. Shortly after his discharge, he states that he began having increasing nasal and sinus congestion, which soon progressed to episodes of wheezing, dry cough, and shortness of breath. He is now having these episodes about four times a week. In addition, he has had these symptoms at night three times in the past month. On physical examination, patient is afebrile, and lung examination reveals prolonged expiration with bilateral expiratory wheezes. He has nasal polyps. The peak expiratory flow is 85% of predicted. Which of the following would be the most appropriate management of this patient's condition? (A) Increased dose of inhaled steroids (B) Add a long-acting beta-agonist (C) Add theophylline (D) A short course of oral steroids tapering over 4 weeks (E) Add a leukotriene modifier Record # 37 Question/Fact:

A 29-year-old woman presents to the office complaining of intermittent hemoptysis. On further questioning, she reveals that she grows tired after doing minimal office work. She is unable to jog the usual two miles that she used to do until just last year. She lived in India until the age of nine. Physical examination shows: temperature 98.7 F, blood pressure 130/70 mm Hg, respirations 18/min, and pulse 90/min. Rales are heard at the bases of both lungs. Heart examination reveals a loud S1, a split S2, and an opening snap followed by a low-pitched, early diastolic rumble. No edema or ulcers are noted on the extremities. EKG shows a normal sinus rhythm at 85/min; tall, peaked P waves; and P pulmonale. Straightening of the left heart border and prominent pulmonary vasculature are seen on the chest x-ray. As her disease worsens, what would you expect to find on auscultation? (A) Development of an S3 gallop (B) Development of an S4 gallop (C) The opening snap moving further away from the S2 (D) The opening snap moving closer to S2 Record # 38 Question/Fact: What is the appropriate mode of colorectal cancer screening for the following case? A 60-year-old man with occult-positive stool but took aspirin; an upper endoscopy that showed a large gastric ulcer; and a normal colonoscopy at age 52. (A) Colonoscopy now and every 10 years (B) Flexible sigmoidoscopy now and every 5 years (C) Colonoscopy at age 50 and every 10 years (D) Colonoscopy now and every 10 years (E) Stool occult cards every year; colonoscopy if positive (F) Colonoscopy at age 40 and every 5 years (G) Colonoscopy in 3 years (H) Colonoscopy in 1 year (I) Colonoscopy every 1 to 2 years Record # 39 Question/Fact: A 50-year-old man presents with a 3-week history of fatigue, generalized body aches, and a decreased appetite. He states that in the past few weeks he has stopped playing golf three times a week due to dyspnea and fatigue while walking on the course. While brushing his teeth, he has noticed that his gums bleed more easily. He shows you multiple erythematous nodules over his upper extremities. For the past few days, he has been coughing greenish-yellow sputum, and his temperature while at home was 100.9 F. He appears pale and in mild respiratory distress. Vital signs are: temperature 100.7 F, pulse 105/min, and respiratory rate 23/min. You see multiple petechiae on the hard palate. On lung examination, there are rales at the right base with tactile fremitus and egophony. You cannot feel his spleen. You notice multiple erythematous nodules along his arms. Laboratory studies and a peripheral smear show the following: WBC 80,000/mm3, neutrophils 60%, blasts 8%, lymphocytes 30%, hemoglobin 10 mg/dL, hematocrit 29%, platelets 40,000/mm3. Blasts are present on the peripheral smear. What is the next best step in the management of this patient? (A) Leukapheresis (B) Daunorubicin and cytarabine (C) Platelet transfusion (D) Bone marrow transplant (E) All-trans-retinoic acid (ATRA) Record # 40 Question/Fact: A 24-year-old woman with a history of SLE presents to your office in the seventh month of her first pregnancy. She has been having intermittent episodes of headaches associated with some nausea and vomiting over the past week. Her lupus has been well controlled on low-dose prednisone. Her normal blood pressure is 125/80 mm Hg. Her urinalysis and creatinine concentrations were normal at the last visit. Anti-Ro, anti-La, and antiphospholipid antibodies were negative at the onset of her pregnancy. Today her blood pressure is 135/85 mm Hg, with a pulse of 80/min. Her physical examination and fetal monitoring is unremarkable. Today's urinalysis shows proteinuria, erythrocytes, and erythrocyte casts. Her creatinine is 1.7 mg/dL. The complete blood count and liver function tests are normal. Complement levels show low levels of C3 and C4. What would be most appropriate as the next best mode of therapy?

(A) Bedrest (B) Magnesium sulfate (C) Cyclophosphamide (D) Azathioprine (E) Emergent cesarean section (F) Methotrexate Record # 41 Question/Fact: A 55-year-old woman comes to the clinic after being diagnosed with type 2 diabetes mellitus during a routine screening performed at work. She is currently asymptomatic and denies any history of frequent urination. On physical examination, you note a normal blood pressure. Her heart, lungs, and the remainder of the physical examination are within normal limits. When you ask the nurse to weigh your patient, you note her BMI to also be within normal limits. What is the next step in the management of this patient? (A) Begin intense insulin therapy (B) Begin glipizide (C) Begin pioglitazone (D) Begin acarbose (E) Begin metformin Record # 42 Question/Fact: A 38-year-old healthy man comes to the emergency department for the onset of a stroke. The patient reports that he had several weeks of malaise and feeling feverish. There has been some dyspnea as well. He has also lost 10 pounds over the last several weeks. He has no previous cardiac history. On physical examination, his temperature is 37.9 C (100.2 F), blood pressure is 90/60 mm Hg, and the pulse rate is 100/min and regular. Apart from the neurologic deficits, the rest of physical examination is remarkable for a diastolic murmur, which changes markedly with bodily position. The erythrocyte sedimentation rate (ESR) is 67 mm/min. What is the most likely diagnosis? (A) Aortic stenosis (B) Infective endocarditis with ruptured valve (C) Left atrial myxoma (D) Rheumatic fever (E) Left ventricular mural thrombus

Record # 43 Question/Fact: A 35-year-old man with no significant past medical history comes to the office complaining of malaise, fever, headache, and a diffuse, nonpruritic, maculopapular rash that has spread from his palms and soles over the last ten days. A recent test for HIV was negative. On physical examination, he has a temperature of 100.5 F. There are mucocutaneous patches at the angles of the mouth, and the palate and pharynx are inflamed. He has generalized adenopathy with a maculopapular rash on the margins of the ribs, lateral trunk, and all four extremities. The rash on the palms and soles is hyperpigmented with a superficial scale. There is a large, pale, flat-topped papule found in the perineum. What would be the test of choice to follow this patient's response to treatment? (A) Darkfield microscopy (B) FTA-ABS (C) MHA-TP (D) VDRL (E) Serial clinical examinations Record # 44 Question/Fact: A 38-year-old woman is admitted with an excruciating headache, photophobia, nausea, and vomiting for the last hour. Her temperature is 98 F, and her blood pressure is 172/90 mm Hg. She has a stiff and painful neck with no focal neurological deficits and no cranial nerve palsies. A CT scan of her head reveals the

presence of a subarachnoid hemorrhage with no intraparenchymal blood. A four-vessel angiogram does not reveal the source of bleeding, and there are no aneurysms or arteriovenous malformations. She is started on nimodipine and is stable for six days. On the sixth day, she develops mild weakness of the right arm and leg. She is awake, alert, and oriented, and is in no respiratory distress. She is now afebrile with a blood pressure of 128/62 mm Hg. A repeat CT scan of the head shows no evidence of fresh blood. The transcranial Doppler shows increased velocity of blood flow and narrowing in the middle cerebral artery. What is the next step in management? (A) Repeat angiogram (B) Increase the mean arterial pressure with crystalloids and dopamine (C) Start antihypertensive medications (D) Intubation and hyperventilation (E) Ventriculostomy Neurology Record # 45 Question/Fact: A 52-year-old woman is complaining of several weeks of swelling of both hands and ankles. She notes stiffness in the morning that subsides during the day. She has also experienced generalized weakness, cough, and intermittent low-grade fevers. The patient denies having a skin rash or dryness of the eyes. Examination reveals symmetrical swelling and warmth of the wrists, knees, and proximal interphalangeal and metacarpophalangeal joints of the hands. There are small subcutaneous nodules palpated over the tendons of her fingers and elbows. A faint pericardial rub is auscultated. Initial laboratory tests reveal: white cell count 11,200/mm3, hematocrit 32%, mean corpuscular volume 92 m3, platelets 660,000/mm3, creatinine 1.2 mg/dL, and glucose 150 mg/dL. What should be the first diagnostic test performed? (A) X-rays of hands, wrists, and ankles (B) Rheumatoid factor and sedimentation rate (C) Antinuclear antibody (D) Examine the synovial fluid (E) Echocardiogram Record # 46 Question/Fact: A 27-year-old homosexual man presents to the emergency department complaining of worsening anal and rectal pain over the past two weeks. There is an occasional rectal discharge containing mucus and blood. He reports feeling the urge to defecate multiple times during the day, but often he is unable to have a bowel movement. For the past three days, he has had high fevers associated with shaking chills, night sweats, arthralgias, and myalgias, all of which started two days ago. He has a temperature of 103.2 F and a heart rate of 115/min. There is marked bilateral inguinal and femoral lymphadenopathy. Digital rectal examination shows marked tenderness and a scant, purulent, blood-tinged discharge. No masses are palpated. The genital examination is within normal limits. His white cell count is 17,500/mm3.. The complement fixation test is strongly positive. Flexible sigmoidoscopy shows ulcerative proctitis with areas of mucosal bleeding and purulent exudates. The rectal biopsy shows crypt abscesses with marked inflammatory cell invasion and granulomas with giant cells within the mucosa. Which of the following is the best treatment for this patient? (A) Sulfasalazine (B) Metronidazole (C) Corticosteroids (D) Doxycycline (E) Chemotherapy and/or radiotherapy Record # 47 Question/Fact: A 55-year-old man with no significant history comes to the office complaining of fatigue and abdominal fullness for a month. He claims that over the past year, he has been admitted to the hospital five times for bacterial pneumonia. The physical examination is remarkable for a massively enlarged spleen and liver. There are no palpable lymph nodes. The remainder of the examination is unremarkable. Laboratory studies show: WBC 1,100/mm3, hemoglobin 8.5 mg/dL, hematocrit 25%, platelets 34,000/mm3 (neutrophils 40%, lymphocytes 58%, monocytes 0%, eosinophils 2%). A bone-marrow aspirate was attempted but was unsuccessful. What is the best treatment for this patient? (A) Interferon

(B) Hydroxyurea (C) Fludarabine (D) Cladribine (E) Cyclophosphamide, vincristine, and prednisone Record # 48 Done till here Question/Fact: A 75-year-old white woman presents to your primary care clinic for a routine visit. She has a history of type II diabetes mellitus and essential hypertension. She currently takes insulin NPH 25 units in the morning, 15 units in the evening, and 5 units of regular insulin at bedtime. She also takes hydrochlorothiazide 25 mg daily. She does not have any physical complaints. Her blood pressure is 130/80 mm Hg. HgbAlc in the clinic is 7.0%. You also do a urinalysis, and it is negative for protein and ketones. Her baseline BUN is 15 mg/dL, and the creatinine is 1.0 mg/dL. What is the next best step in managing this patient? (A) 24-hour urine for microalbumin (B) Morning spot urine for albumin/creatinine (C) Check the urine protein level under different postures (D) Low protein diet (E) Increase morning insulin dose to 30 units Record # 49 Question/Fact: A 60-year-old man has an episode of loss of consciousness for 60 seconds while walking to his bedroom. Prior to the episode, the patient was lightheaded, nauseated, and diaphoretic. His wife noticed jerking of the upper extremities upon falling to the ground. He seemed to be transiently dazed but was soon alert and recovered completely. Two weeks ago, he had a similar episode of loss of consciousness. The patient has a history of lung cancer diagnosed 6 months ago. He underwent lobectomy and chemotherapy. He is afebrile with a regular heart rate of 62/min. His blood pressure is 100/60 mm Hg with no orthostatic changes. Cardiovascular examination reveals normal heart sounds with no murmurs. There are no carotid bruits. The neurological examination is normal. There are no laboratory abnormalities. EKG shows a sinus rhythm with no abnormalities. The head CT scan is normal. Which of the following will most likely reveal the etiology of the episode of loss of consciousness? (A) Brain biopsy (B) Electroencephalogram (C) 24-hour Holter monitoring (D) Tilt-table testing (E) MRI of the brain (F) Echocardiogram

Record # 50 Question/Fact: A 30-year-old woman with a past medical history of severe asthma since childhood presents to the emergency department complaining of dysuria. She was started on prednisone four months ago for her asthma and has been taking ibuprofen for lower back pain for four months. On physical examination, her blood pressure is 140/80 mm Hg, and the rest of her physical examination is normal, except for 3+ pitting edema bilaterally. Urinalysis shows: protein 4+, erythrocytes 2-3/hpf, occasional fat bodies, white cells 10-20/hpf. Serum albumin 2.4 g/dL; cholesterol 440 mg/dL; C3 normal; 24-hour urine protein 6 g/d; sodium 149 mEq/dL, potassium 4.1 mEq/L, bicarbonate 24 mEq/L, BUN 26 mg/dL, creatinine 1.4 mg/dL, glucose 90 mg/dL. She is sent for a renal biopsy, which, under electron microscopy, shows effacement of the epithelial foot processes. What is the most effective treatment for her renal disease? (A) Stop the NSAIDs and observe (B) Cyclophosphamide (C) Cyclosporine (D) Captopril (E) Interferon Record # 51 Question/Fact:

A 77-year-old man comes to your office for a PPD reading. The patient recalls being told he was PPD-negative thirty years ago. The patient has a history of hypertension, ischemic bowel disease, and gastric cancer, and his medications are prednisone 10 mg daily, multivitamins, and losartan. The patient denies exposure to anyone with active tuberculosis and has lived in Queens, New York, his whole life. He is a retired stockbroker and now works in a homeless shelter. He denies drinking alcohol or smoking tobacco but admits to occasional prostitute relations. You measure an area of erythema of 18 mm and an area of induration of 11 mm. His chest x-ray is normal. What would your next course of action be? (A) Nothing further is necessary (B) Isoniazid for six months (C) Isoniazid for nine months (D) Repeat the PPD in one year (E) Check three sputum acid-fast stains Record # 52 Question/Fact: A 52-year-old woman is admitted to the hospital with fever up to 102 F, shortness of breath, and a cough with production of yellowish sputum for the past three days. She has a history of severe arthritis for the past twenty years. Over the past two years, she has lost about thirty pounds. She has a history of frequent admissions to the hospital with recurrent pneumonias and skin abscesses. Her medications include celecoxib, omeprazole, and methotrexate. Physical examination reveals a pale, thin, ill-looking woman. Her temperature is 101.6 F, blood pressure is 110/68 mm Hg, and respiratory rate is 24/min. Submandibular and cervical lymph nodes are two centimeters is size and are mobile, soft, and painless on palpation. The wrists, elbows, knees, ankles, metacarpophalangeal joints, and proximal interphalangeal joints are severely deformed bilaterally and have restriction in the range of motion. Palpation of elbows and Achilles tendons reveals small, subcutaneous nodules. There are multiple ulcerations, ecchymoses, and skin hyperpigmentation of both lower extremities. Lung auscultation reveals rales and dullness on percussion over the right lung base. The chest x-ray reveals right lower lobe pneumonia. The spleen is palpable, and the liver has a span of 15 cm. Her white cell count is 2,500/mm3 with a hemoglobin of 6.8 mg/dL, a hematocrit of 20.6%, and platelets of 80,000/mm3. Which test would be most helpful to determine the right initial mode of treatment? (A) Bone-marrow biopsy (B) Peripheral smear examination (C) Lymph node needle biopsy (D) Synovial fluid analysis (E) Skin biopsy Record # 53 Question/Fact: A 58-year-old man with no previous past medical history presents to the emergency department complaining of dizziness for one week accompanied by headache, nausea, generalized weakness, decreased appetite, and weight loss. He is a 30-pack-year smoker and denies cough, shortness of breath, or hemoptysis. The patient appears cachectic on physical examination and is in no acute distress. Vital signs are normal. Physical examination is remarkable for diminished breath sounds in all lung fields and symmetrically enlarged breasts. The neurologic examination is normal. Chest x-ray shows hyperinflated lungs with a peripheral lesion in the right upper lobe and a central left-upper-lobe lesion. The head CT scan reveals a left posterior fossa lesion with edema and mass effect. Chest CT shows a 5-cm mass in the periphery of the right upper lobe and a 3-cm mass within 2 cm of the carina in the left middle lobe. Mediastinoscopy and biopsy are performed, and the biopsy shows large-cell cancer. How would you best manage this patient at the present time? (A) Preoperative pulmonary function testing (PFT) (B) Radiation therapy to the brain and dexamethasone (C) Radiation therapy to lung lesions (D) Combination of chemotherapy and radiation therapy Record # 54 Question/Fact: A 56-year-old woman with a history of asthma since childhood presents to her physician's office because of a cough of 3 to 4 weeks' duration. The patient states that the cough produces yellowish sputum and is associated with fever and some difficulty breathing. She recently completed a course of oral antibiotics without improvement. The patient also reports generalized weakness, fatigue, anorexia, and night sweats over the same time period. Her HIV test was negative 2 years ago.. The patient is afebrile with mild respiratory distress. There is scattered wheezing upon auscultation of the lungs. Laboratory studies show: WBC 6,000/mm3,

differential: neutrophils 47%, lymphocytes 18%, eosinophils 32%; and hematocrit 39%. Chest x-ray shows bilateral peripheral infiltrates and a small right pleural effusion. What is your plan for this patient? (A) Sputum culture (B) Bronchoscopy for lavage and transbronchial biopsy (C) Thoracentesis (D) High-resolution chest CT scan with contrast (E) Open lung biopsy Record # 55 Question/Fact: A 76-year-old man returns to your clinic for a follow-up appointment after having an echocardiogram and a Holter monitor done. Both test results are normal. The patient has been having sensations of a rapid heartbeat for several years. He describes these episodes as "a strange pounding in my heart" occurring suddenly and ending spontaneously. He has never had syncope, and these episodes are not associated with dyspnea or chest pain. On physical examination, his pulse is 64/min and regular, and blood pressure is 142/78 mm Hg. The rest of his examination is within normal limits. A repeat EKG shows a normal sinus rhythm, without change from earlier EKGs. An event monitor is put in place. Three months later, you receive a report from the cardiologist that reveals paroxysms of atrial fibrillation with a rapid ventricular response that ends spontaneously. What is the most appropriate management for this patient's paroxysmal atrial fibrillation at this time? (A) Begin aspirin 325 mg once a day (B) Elective cardioversion (C) Transesophageal echocardiogram (D) Begin warfarin and adjust the dose based on INR (E) Send the patient for electrophysiologic testing (EPS) Record # 56 Question/Fact: A 35-year-old healthy white woman presents to your office complaining of three weeks of bleeding gums after she brushes her teeth. She otherwise feels well and has no other complaints. Her dentist says that she has healthy teeth and gums. She has no significant past medical history and does not take any medications. She is a nonsmoker and does not drink alcohol. She is married and has two healthy young children. Physical examination: blood pressure 132/72 mm Hg; heart rate 60/min; respiratory rate 12/min; temperature 98.5 F HEENT: good dentition; no gingival hypertrophy or discoloration; no gingival tenderness upon palpation; no oral lesions Heart: S1, S2, no murmurs Extremities: no edema White blood cell count 5,600/mm3; hematocrit 41%; platelets 9,000/mm3 Which of the following is the most specific finding for this patient's condition? (A) An enlarged spleen (B) A positive monospot test (C) A diminished number of megakaryocytes (D) Antiplatelet antibodies (E) Hemolysis on peripheral smear (F) Increased megakaryocytes Record # 57 Question/Fact: A 45-year-old woman with a history of hypertension for the past 10 years presents to your office complaining of intermittent headaches, increased thirst, and muscle weakness over the past two months. She also noticed that she has been urinating more often than usual. She denies any recent infections. On physical examination, the blood pressure is 160/100 mm Hg, and heart rate is 68/min. The rest of the examination is unremarkable. Laboratory studies show: sodium 154 mEq/L, potassium 2.9 mEq/L, BUN 21 mg/dL, and creatinine 0.9 mg/dL. Plasma renin activity is 0.2 g/L (normal 0.9-3.3 g/L); 24-hour urine aldosterone is 50 g/d on a high salt diet (normal 1.5-12.5 g/24 h); 18-hydroxycorticosterone 10 is g/dL (normal <85 g/dL); aldosterone at 8 AM supine is 35 g/dL (normal 310 g/dL); and aldosterone at 12 noon upright is 36 g/dL (normal 5-30 g/dL). What is the most likely etiology?

(A) Bilateral adrenal hyperplasia (B) Addison's disease (C) Conn's syndrome (D) Liddle's syndrome (E) 17-alpha-hydroxylase deficiency Record # 58 Question/Fact: A 20-year-old male college student is found passed out in the stairwell of his dormitory, unresponsive to pain or verbal stimuli. No further history is obtainable from the patient, and no other dormitory residents are able to give any additional history. The initial vital signs at the site are: blood pressure 110/58 mm Hg, pulse 78/min, and respirations 16/min. The ambulance technician gives 2 mg of naloxone, with very little response. The patient is then transported to the nearby emergency room. The patient appears to be a disheveled male with alcohol on his breath. The patient is responsive and cooperative to commands; however, he has difficulty with answering questions. The remainder of the examination is unremarkable. Initial laboratory studies reveal: Sodium 132 mEq/L; potassium 5.4 mEq/L; bicarbonate 20 mEq/L; chloride 96 mEq/L; BUN 34 mg/dL; creatinine 2.9 mg/dL; glucose 108 mg/dL; alcohol level 9 mg/dL (low). Urine dipstick is negative for leukocytes, nitrites, and blood. Which of the following tests would you order next to help diagnose the cause of this patient's acute renal failure? (A) Urine specific gravity (B) Urine fractional excretion of sodium (C) CT scan of abdomen and pelvis (D) Serum osmolality (E) Urine myoglobin Record # 59 Question/Fact: A 78-year-old man reports a 2-month history of gradually decreasing exercise tolerance with shortness of breath on exertion. He has a long history of stable angina and hypercholesterolemia. He is currently taking aspirin, metoprolol, furosemide, and atorvastatin. On physical examination, his pulse is 72/min, and his blood pressure is 110/70 mm Hg. Jugular venous pressure is 6 cm H2O. Carotid upstrokes are delayed, left ventricular impulse is displaced laterally, and a systolic thrill is present at the base of the heart. There is a normal S1, a paradoxical split of S2, an S4 gallop, and a grade IV/VI, low-pitched, crescendo-decrescendo midsystolic murmur at the base of the heart. The murmur is transmitted upward along the carotid arteries. Which of the following would you do next? (A) Maximize the beta-blocker dosage (B) Catheterization of the left side of the heart (C) Begin captopril (D) Percutaneous balloon aortic valvuloplasty (E) Start digoxin Record # 60 Question/Fact: A 20-year-old Asian man comes to your clinic complaining of dark-colored urine. He says that "it looks like Kool-Aid" and that it happened only this morning. He says that he has "felt sick for a few days" and has had "the flu" recently. He also noticed multiple "pimples" along his legs and has had some knee and leg pain. He denies medication use and has a history of sickle-cell trait. He denies abdominal pain, nausea, flank pain, or dysuria. On physical examination, his temperature is 98.6 F, pulse is 70/minute, and blood pressure is 110/70 mm Hg. Examination of the pharynx reveals erythema but no exudates. His tonsils appear normal. The heart and lung examination are also normal, and you can't feel liver or spleen enlargement. Along the anterior aspects of his legs, you feel multiple, raised, erythematous papules discretely arranged from the knee to the ankle. Urinalysis shows: a red color; specific gravity 1.015; pH 6.90; no white cells; red cells: 50-100/hpf; red cell casts 5-10/hpf. There is no urobilinogen, glucose, crystals, or nitrites. There is 1+ protein. What is the most accurate diagnostic test?

(A) Serum immunoglobulin A (IgA) level (B) Renal biopsy (C) Serum C3 level (D) 24-hour urine (E) Electron microscopy of a skin biopsy (F) Serum protein electrophoresis

Record # 61 Question/Fact: A 44-year-old man presents to the emergency department with right-sided flank pain and bloody urine for the past four days. The patient denies fever or chills but has had episodes of severe flank pain. He has been known to be HIV positive for the last four years. He has been compliant with his medications, which include Crixivan (indinavir), zidovudine (AZT), and Epivir (lamivudine). The patient denies any previous episodes of the above noted symptoms. He has a temperature of 99.1 F. The urinalysis shows gross hematuria with no white cells. An ultrasound shows an eight-millimeter stone in the renal pelvis with no hydronephrosis. What is the most appropriate long-term management of this patient? (A) Increase hydration (B) Hydrochlorothiazide (C) Percutaneous removal of the stone (D) Stop the indinavir Record # 62 Question/Fact: A 62-year-old man is brought to the emergency department after he was found in the park walking aimlessly and mumbling to himself. The patient appears to be confused and disoriented. His vitals are normal. On neurological examination, the patient's mental status varies from lethargy to periods of extreme agitation marked by crying and shouting out that he sees snakes hanging from the ceiling. He is unable to carry on a conversation but follows simple commands. This is the first emergency department visit for this problem. His speech is normal in fluency. The motor, sensory, and deep-tendon reflex examinations are normal. He has a fine tremor of both hands but no cogwheeling rigidity. Initial laboratory results reveal alcohol in the blood. Which of the following is most likely to be true for this patient? (A) Delusions will improve after treatment with Risperdal (B) Normal EEG (C) Incomplete resolution of cognitive defects, despite appropriate treatment (D) Patient may have underlying dementia secondary to alcohol withdrawal (E) Sleep-wake cycle can be improved by limiting interaction with the patient to regular awake times as much as possible during the hospitalization Record # 63 Question/Fact: A 28-year-old Irish woman presents with a complaint of a pruritic rash on her elbows and knees for the last 2 weeks.. She has a long history of abdominal bloating and occasional diarrhea. There has been no prior hospitalizations or surgeries. She has been taking glyburide for noninsulin-dependent diabetes mellitus. She denies smoking, drinking alcohol, and doesn't take any medications. On physical examination, the patient presents as a thin female with a papulovesicular rash on the elbows and knees. Vital signs are: temperature 98.5 F, pulse 95/min, and blood pressure 120/80 mm Hg. Abdominal examination reveals some distention but no masses. The skin biopsy demonstrates neutrophils at the dermal papillary tips by light microscopy. What would be the best treatment for this patient? (A) Acyclovir (B) Broad-spectrum antibiotics for 1 to 2 weeks (C) Lactase enzyme replacement (D) Dapsone and a gluten-free diet (E) Trimethoprim/sulfamethoxazole Record # 64 Question/Fact: A 52-year-old man presents to the primary care clinic with thinning of his face and wasting of his arms and legs. The patient has a past medical history of HIV

infection. He is on gemfibrozil, ritonavir, lamivudine, and stavudine. He has been compliant with his medications and does not take over-the-counter medications. He is afebrile and in no acute distress. There has been a 6-lb weight loss since the last visit six months ago. There is a soft, nontender, fatty mass noted in the dorsocervical region. The neck is supple and nontender. There is truncal obesity and thinning of the face, arms, and legs. His glucose level is 184 mg/dL, his cholesterol is 260 mg/dL, triglycerides are 340 mg/dL, and his CD4 count is 398/L with an undetectable viral load. What is the next best step in diagnosing this patient's clinical findings? (A) 24-hour urinary cortisol level (B) Dexamethasone suppression test (C) Excisional biopsy (D) No further work-up is needed Record # 65 Question/Fact: A 30-year-old man is brought to the emergency department by his girlfriend after he loses consciousness. He has had similar episodes in the past, but this is the first one his girlfriend has seen. During these episodes, he has been diaphoretic and pale. His girlfriend says that he complained of graying of his vision, lightheadedness, and a sensation of feeling warm. He also had repetitive jerks of his body. This lasted for 45 seconds, and then he became oriented to his surroundings in less than a minute. The patient is thin and underweight and has dry skin, teeth erosions, and brittle nails. He complains of some muscle pain. His prolactin level is normal. What is the most likely diagnosis? (A) Generalized seizure (B) Transient ischemic attack (TIA) (C) Pseudoseizure (D) Syncope (E) Hypothyroidism Record # 66 Question/Fact: A 65-year-old man presents to the hospital with complaints of chest pain of 8 hours' duration. The EKG reveals anterior wall ST elevation. The patient receives aspirin, oxygen, tissue-plasminogen activator, metoprolol, and intravenous nitroglycerin. His symptoms resolve, and serum chemistries reveal a peak CPK of 1,200 U/L and a CKMB of 80 U/L. The patient is transferred to the CCU. His subsequent hospital course is uneventful until Day 3, when the patient develops severe dyspnea. The blood pressure is 120/70 mm Hg, and the heart rate is 120/min. Physical examination reveals a new, loud, holosystolic murmur radiating to the axilla and bilateral rales. What would be the most appropriate initial intervention at this point? (A) Heparin alone (B) Heparin and furosemide (C) Heparin and digoxin (D) Sodium nitroprusside (E) Surgery Record # 67 Question/Fact: A 43-year-old man comes to the office seeking medical advice. His father was diagnosed with gout at the age of 45 years and now needs hemodialysis. His older brother is 50 years old and was diagnosed with gouty arthritis last year. The patient's past medical history is significant for hypertension, which is managed with atenolol. On physical examination, the patient is slightly obese. There are no obvious joint deformities. His range of motion is not restricted. The only significant finding on physical examination is some nodularity on palpation of the Achilles tendon on the left. His serum uric acid is 18 mg/dL (normal 2.5-7.5 mg/dL), and his urine uric acid is 850 mg/24 h (normal <800 mg/24 h on a regular diet). Treatment with allopurinol is started. In two weeks, the patient comes back complaining of a diffuse erythematous rash and itching. What is your next step? (A) Stop allopurinol (B) Stop atenolol (C) Desensitization to allopurinol (D) Give colchicine if an attack develops (E) Repeat the uric acid level in one month Record # 68

Question/Fact: A 65-year-old homeless man with a past medical history significant for alcohol abuse was brought to the emergency department by the local ambulance company after being found outside the local strip mall being loud and reckless. Although he was awake, the patient was unable to give any further history. He is well known to the emergency department for multiple visits for alcohol intoxication. Four hours later, the patient was found to be unarousable even after vigorous noxious stimulation. His temperature is 97.9 F with a blood pressure of 110/65 mm Hg, a heart rate of 88/min, and a respiratory rate of 28/min. His eye examination is normal. He has bilateral rales on lung examination, with a minimally distended, nontender abdomen. His arterial blood gas shows: pH 7.15, pCO2 23 mm Hg, and pO2 88 mm Hg. Laboratory studies reveal: sodium 133 mEq/L, chloride 107 mEq/L, serum bicarbonate 10 mEq/L, BUN 34 mg/dL, creatinine 2.2 mg/dL, and glucose 180 mg/dL. The ethanol level is 46 mg dL, with a serum osmolality of 305 mOsm/kg. Urinalysis shows no protein, ketones, or white cells, but crystals are present. What is the definitive treatment for this patient? (A) Pyridoxine and thiamine (B) Fomepizole (C) Hemodialysis (D) Ethanol infusion (E) Gastric lavage Record # 69 Question/Fact: A 72-year-old woman comes to the emergency department with 40 minutes of severe substernal chest pain. The pain does not change with respirations or bodily position. She has never been in your hospital before. She has a history of hypertension and diabetes for which she is maintained on an ACE inhibitor. Physical examination shows a normal blood pressure. There are no abnormalities found on physical examination. An EKG shows a left bundle branch block. She was given an aspirin to chew on her way into the emergency department. Which of the following will benefit this patient the most? (A) Metoprolol (B) Thrombolytics (C) Nitrates, morphine, and oxygen (D) Lidocaine (E) Low molecular weight heparin Record # 70 Question/Fact: A 67-year-old man presents to the emergency department with dyspnea that has been worsening over the last 2 to 4 days. His chest x-ray shows a large pleural effusion. After admission to the hospital, treatment with diuretics produces only a minimal response in his respiratory status. He undergoes a thoracentesis, which did not improve his symptoms. He quit smoking 3 years ago but had a 120-pack-year smoking history until then. Currently, he has a temperature of 100..3 F and a respiratory rate of 24/min. He has dullness to percussion three-quarters of the way up on one side. Laboratory studies on the pleural fluid show: LDH 1, 505 mg/dL, white cells 500/mm3, red cells 1,030/mm3, and glucose level 76 mg/dL. No bacteria is seen on Gram stain, and the pleural fluid has a pH of 7.5. The cytology is positive for malignant cells. Repeat chest x-ray shows a large pleural effusion on one side. What is the next best step in the management of this patient? (A) Serial thoracentesis (B) Video-assisted thoracoscopy (C) Chemotherapy and radiotherapy (D) Pleurodesis with doxycycline (E) Chest tube placement Record # 71 Question/Fact: A 40-year-old obese African American woman is found to have developed a severe, uniform, erythematous, desquamatous rash, fever, increased liver function tests, and eosinophilia. The patient looks toxic. The patient has a past medical history of renal insufficiency secondary to poorly controlled hypertension, migraine headaches, gout, and systemic lupus erythematous. The patient is on a number of medications to treat her various illnesses. Which of the following medications is the most likely cause of these symptoms? (A) Amlodipine (B) Prednisone (C) Sumatriptan

(D) Allopurinol (E) Colchicine Record # 72 Question/Fact: A 57-year-old Greek man presents to your office for an initial visit. He has no symptoms and feels generally well. He has no past medical history and denies taking any medications. On physical examination, there is no jaundice, and his abdomen is soft and nontender. Blood pressure is 110/70 mm Hg; and pulse is 76/min. Rectal examination shows guaiac-negative, brown-appearing stool, and there is no evidence of hemorrhoids. Laboratory studies reveal the following: Hemoglobin: 10.6 g/dL Hematocrit: 32% Platelets: 350,000/mm3 MCV: 65 FL RBC: 6.8 million/mm3 (normal 4.2-5.9 million/mm3) Reticulocyte index: 2.8 RDW: 14% (normal 13-15%) What is the most accurate test to confirm your diagnosis? (A) Complete iron studies (B) Bone marrow biopsy (C) Peripheral smear (D) Hemoglobin electrophoresis (E) Colonoscopy Record # 73 Question/Fact: A 25-year-old man presents to the clinic with diarrhea and abdominal pain for one day after eating with his family at a restaurant. He also admits to having generalized aches in his lower extremities for the past several weeks. Two weeks ago, he had an upper respiratory tract infection with coryza and a sore throat, which has subsided. Upon examination, he has a temperature of 100 F, a macular rash on the face, purpuric skin lesions on both the lower extremities and back, and minimal tenderness around both ankles with no soft tissue swelling. Urine analysis shows proteinuria, red cell casts, and hematuria. The stool guaiac is positive. BUN is 43 mg/dL, and creatinine is 3.7 mg/dL. What is the most accurate method of diagnosis? (A) Skin biopsy (B) Serum IgA levels (C) Response to prednisone (D) Renal biopsy (E) 24-hour urine Record # 74 Question/Fact: A 62-year-old man is brought to emergency department after being found unresponsive by his wife in their apartment an hour ago. According to the wife, the patient has a history of anxiety and difficulty sleeping, which are being treated with diazepam. He also has depression, which is well controlled with imipramine. The patient uses metoprolol for hypertension and acetaminophen for "aches and pains." He is unresponsive to verbal stimuli. The withdrawal response to painful stimuli is sluggish, and there is occasional muscle twitching. The skin is flushed, and there are dry mucous membranes. The pupils are constricted, and the gag reflex is absent. The temperature is 101 F, with a heart rate of 59/min, a respiratory rate of 9/min, and a blood pressure of 85/50 mm Hg. The oxygen saturation is 85% on room air. The chest, heart, and abdomen examinations are normal. The EKG shows a widened QRS. The patient was intubated by the paramedics and was given administered dextrose, thiamine, and naloxone. What is the best management for this patient? (A) Administer flumazenil, acetylcysteine, and sodium bicarbonate and induce vomiting (B) Administer sodium bicarbonate and perform gastric lavage (C) Give bolus of saline, acetylcysteine, sodium bicarbonate, and charcoal (D) Administer flumazenil, acetylcysteine, normal saline, and charcoal (E) Provide supportive Record # 75

Question/Fact: A 34-year-old woman presents with complaints of asthma, which is worse at night. She has been using an albuterol inhaler with some relief of symptoms. She has a history of heartburn. On occasion, she uses famotidine, which she says improves her heartburn and asthma. She wonders if she needs the albuterol inhaler. What would be the most accurate test to evaluate if her asthma is related to gastroesophageal reflux disease? (A) Upper endoscopy (B) Barium swallow (C) 24-hour ambulatory esophageal pH (D) Esophageal manometry (E) Overnight nuclear medicine scan Record # 76 Question/Fact: A 25-year-old woman with known multiple sclerosis comes to your clinic complaining of urinary hesitancy. She states that her symptoms have begun gradually over the last 3 months and have progressively worsened. Cystometrics show bladder hypertonicity with sphincter dyssynergy. What is the treatment of choice for this patient's symptoms? (A) Oxybutynin (B) Oxybutynin and intermittent bladder catheterization (C) Amitriptyline (D) Bethanechol (E) Amantadine Record # 77 Question/Fact: A 34-year-old woman is admitted with one week of hemoptysis, a low-grade fever, and a 15-pound weight loss over the last two months. There are no chills or night sweats. She uses trimethoprim/sulfamethoxazole (Bactrim) intermittently for recurrent respiratory tract infections. Currently, her temperature is 100 F with a heart rate of 92/min, a respiratory rate of 18/min, and a blood pressure of 138/82 mm Hg. Her chest has bronchial breath sounds on auscultation of the left upper lung field. Her BUN is 26 mg/dL, and creatinine is 2.0 mg/dL. The C-ANCA is positive. Chest x-ray shows a cavitary lesion in the left upper lobe. Her urinalysis shows 2+ proteinuria with 20-30 red cells/hpf, but no red cell casts. What is the most specific diagnostic test? (A) Bronchoalveolar lavage with transbronchial biopsy (B) Open lung biopsy (C) Renal biopsy (D) 24-hour urine protein and creatinine clearance (E) CT scan of the chest with needle biopsy (F) Nasal biopsy Record # 78 Question/Fact: A 67-year-old woman presents to your clinic with a chief complaint of palpitations that occur on and off for the past week. She states that she has been experiencing this problem for many months, but the problem always resolved on its own and would only last for several minutes. Recently, the palpitations have become more frequent and are disturbing her daily routine. She has a past medical history of hypertension and diabetes and was diagnosed with atrial fibrillation two years ago. Cardioversion was attempted twice but failed, and she is now taking coumadin daily. Her blood pressure is 130/85 mm Hg, and the pulse is irregularly irregular at a rate of 110/min. The INR is 2.l. Which of the following is true for this patient? (A) Chemical ablation with alcohol is the next treatment of choice. (B) Chemical ablation with phenol is the next treatment of choice. (C) Tip catheter with standard radiofrequency at a tip temperature of 95 C is the next best step. (D) Tip catheter with standard radiofrequency at a tip temperature of 70 C is the next best step. (E) There is no need for treatment at this time. Record # 79

Question/Fact: A 30-year-old woman with a history of infection with HIV and hepatitis C is admitted for right-knee swelling and pain, a low-grade fever, and cough. The right leg has been getting increasingly painful and swollen over the past few days. She was discharged three weeks ago from a different hospital with a diagnosis of tuberculosis. Her medications after discharge were rifampin, isoniazid, pyrazinamide, ethambutol, Bactrim, and fluoxetine. She does not remember the doses. Her temperature is 100.2 F, blood pressure is 145/92 mm Hg, and the physical examination is only remarkable for an erythematous, swollen, tender right knee. What is the most likely etiology of this problem? (A) Isoniazid (B) Pyrazinamide (C) Ethambutol (D) Interaction between fluoxetine and antituberculosis medications (E) Rifampin Record # 80 Question/Fact: A 27-year-old woman seeks the advice of her primary medical doctor because of progressive swelling of the right knee. She also complains of mild rectal discharge and pain in her wrists and ankles. She is afebrile. She has some mild pharyngeal injection, and the lungs and abdomen are normal. There is no rash evident. Examination of the lower extremities reveals an erythematous and edematous right knee with tenderness over the tendon sheaths of the ankles and wrists. Which of the following procedures is most likely to yield a diagnosis in this patient? (A) Arthrocentesis and culture of the synovial fluid (B) Blood culture (C) Gram stain of the synovial fluid (D) Cervical Gram stain (E) Culture of the urethra, cervix, rectum, and pharynx